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IX.

NURSING CARE PLAN


Asessment Nursing Diagnosis Excess fluid volume related to renal insufficiency. Scientific Explanation CKD is a condition which kidneys lose their ability to remove waste and excess water from bloodstream that canlead to edema. (Brunner & Suddarths textbook of MSN 10th edition volume 2) Planning Intervention Monitored daily patients weight and weigh daily. Rationale Facilitate accurate measurement and obtain baseline data. To prevent accumulation of fluid in the body. Helps reduce extracellular volume Evaluation

Subjective Data: namamanas ang paa at mukha ko Objective Data: Bipedal edema (2mm) Ocular edema With bounding pulse Weight VS

After 8 hours of nursing intervention the edema of the patient will be lessen.

The patients edema lessened from 2mm to 1mm Patient was endorsed for continuity of care.

Advised patient to elevate feet.

Instructed patient about restricting fluid intake. IVF regulated

Instructed patient regarding restriction of dietary sodium.

Decrease sodium facilitate fluid retention.

Increase

Advised patient to cope with the discomforts resulting from fluid retention.

patients comfort promotes compliance with dietary restriction.

Explained the rationale for dietary restriction and relationship to kidney disease.

Promotes compliance with dietary restriction.

Assessment

Nursing Diagnosis Activity intolerance related to generalized weakness.

Scientific Explanation Imbalance body fluid and electrolytes and blood chemistry can result to muscle weakness

Planning

Intervention Monitor VS before and after activity

Rationale Dyspnea may indicate need for further alteration in exercise regimen. Adequate energy reserves required for activity

Evaluation . The patient will perform activity with minimal supervision..

Subjective Data: pakiramdam ko hinang hina ako Objective Data: Weak in appearance Pale Restless VS

After 8 hours of nursing intervention the patient will be able to perform activity with minimal supervision.

Assessed nutritional status

Promoted independence in self care activities as tolerated. Provided patient food preferences

Promotes improve self esteem

Increase dietary intake

within dietary restriction.

encouraged

Encouraged adequate rest especially before meals

Rest between activity provides time for energy conservation

Encouraged high caloric, low protein, low sodium and low potassium snacks between meal.

Reduces source of restricted food and provide calorie for energy.

Encouraged ROM

Maintain muscle strength.

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